Provider Demographics
NPI:1700539780
Name:INTEGRATED WOUND CARE ILLINOIS PLLC
Entity Type:Organization
Organization Name:INTEGRATED WOUND CARE ILLINOIS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUSAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-963-3495
Mailing Address - Street 1:492C CEDAR LN STE 514
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-1713
Mailing Address - Country:US
Mailing Address - Phone:718-963-3495
Mailing Address - Fax:
Practice Address - Street 1:801 ADLAI STEVENSON DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-4261
Practice Address - Country:US
Practice Address - Phone:718-963-3495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty